I've noticed a major transformation in the way the hospital practices medicine in the six years I've been at Happy's hospital. When I first started we didn't have things like ORYX measures. These are things that your fine government has decided are the golden road to quality. It used to be voluntary. Then it wasn't. Now, if you don't submit quality data, you get dinged several % of your total revenue take from the Medicare National Bank (MNB). If you're looking at a 500 million dollar take, 1% could be 5 million dollars. That's a lot of money in an industry who's margins run in the low single digits. And they run that way because they are forced to hire folks and provide health insurance and retirement plans for folks who do nothing more than audit charts and organize the data for delivery to the Joint Commission to guarantee that their employer gets their 5 million dollar pay day.
All of this quality medicine being delivered by hospitals is supposed to be improving outcomes. Right? I mean, give everyone with pneumonia the pneumovax shot and we should see a decrease in pneumonia admissions. Right? That should translate into fewer dollars being spent by the MNB. Right? Give your heart failure patients an ACEi, assess their LV function, give them smoking cessation advice, and give them heart failure associated discharge instructions and they should do better. Right? They should get admitted less often. Right?
Well, not so fast. The Journal of the American Medical Association in its August 19th edition is reporting on an editorial by Drs Gregg Fonarow and Eric Peterson. They make a fine case that all the money being spent on data gatherers, chart police and data processors have done nothing but increase the cost of delivering care in this country and have not changed outcomes one bit . It's a fascinating read.
Heart failure is one of the most common causes of death and a top reason for hospitalization in this country. For Medicare beneficiaries, it is the most common cause of 1-year readmissions and mortality with 65% and 35% respectively. So it makes sense for the MNB to force hospitals into doing things that should prevent both. Right?
In 1996, the MNB aligned with the Joint Commission to create national standards for heart failure performance measures. As I stated above, these were
- measuring LV function
- using ACEi in those with with LV dysfunction (and now ARBs too)
- providing complete HF discharge instructions
- counseling on smoking
In 13 years these performance measure have remained steadfast. The editorialists note that it takes a hospital a conservative estimate of 22.2 minutes per heart failure case to abstract the data for delivery , which accounts for 400,000 person-hours spent each year by US hospitals. And that is just for heart failure patients. This doesn't include the person-hours spent abstracting the data on other ORYX measures which include AMI, pneumonia, pregnancy, psych services, children's asthma, surgical improvement (SCIP), VTE, stroke and hospital outpatient measures.
They also appropriately note the expensive IT support, which can run in the millions of dollars for implementation of the systems processes required for reporting to the JC.
One would expect a return on investment for the MNB for forcing hospitals to spend millions of dollars to implement process to improve outcomes. Right?
What the doctors found was a dramatic improvement in the reporting of the performance metrics. From 2002 - 2007 , discharge instructions improved from 31% to 78%, LV assessment improved from 82% to 95%, use of ACEi or ARB improved from 74% to 90% and smoking cessation counseling went almost universal from 42% to 96%.
These are dramatic improvements. Clearly, when hospitals risk losing millions, implementing systems process to meet mandated performance metrics are seen as imperative. Hospitals will spend millions to meet their regulatory obligations as set forth by the MNB or risk losing millions of dollars for not.
So what did the outcomes data show with regards to one year readmission rates and one year mortality for heart failure patients in the MNB over this six year period of dramatic performance metric improvements?
It showed no change in re admissions or one year mortality.
The most likely explanation is the right explanation. In other words the performance metrics chosen by the MNB and raised to God like status in the race to quality are one more example of junk science.
As the authors note, only one of the four measures are supported by direct clinical trial evidence. And of six therapies demonstrated in randomized clinical trials to reduce morality, five of them were not included as performance metrics.
In other words, what we have here is institutionalization of junk science. Forcing hospitals and doctors to do things that have no change in outcomes, cost millions upon millions of dollars to implement, and have no beneficial effect on patients or the wallet of the American tax payer.
With that I say anyone who wishes more government control upon medicine should walk cautiously with both eyes wide open. You get what you pay for. In this case, you get a bunch of performance measures with near universal acceptance by hospitals all across this country, costing hundreds of millions of dollars a year, and no benefit to anyone except those who do their job day in and day out collecting worthless information while the rest of America struggles with the high cost of health care.
Any you wonder why American medicine is so expensive.
